l“1 

SANITARY COMMISSION. 




v 

' 




OF A 


COMMITTEE OF THE ASSOCIATE MEDICAL MEMBERS OF 

THE SANITARY COMMISSION, 


ON THE SUBJECT OF 


AMPUTATIONS THROUGH THE FOOT, 

AND AT THE ANKLE-JOINT. 

S> * 

n 


NEW YORK: 

PRINTED BY R. CRAIGHEAD, 
Caxtoit jfiull&tttjj, 

81 , 83 , and 85 Centre Street. 

1862. 












<P 


Q 


The attention of the Sanitary Commission has been directed to 
the fact, that most of our Army Surgeons, now in the field, are 
unavoidably deprived of many facilities they have heretofore en¬ 
joyed for the consultation of standard medical authorities. It is 
obviously impossible to place within their reach anything that 
can be termed a medical library. The only remedy seems to be 
the preparation and distribution among the medical staff, of a 
series of brief essays or hand-books, embodying, in a condensed 
form, the conclusions of the highest medical authorities in regard 
to those medical and surgical questions which are likely to present 
themselves to surgeons in the field, on the largest scale, and which 
are, therefore, of chief practical importance. 

The Commission has assigned the duty of preparing papers on 
several subjects of this nature, to certain of its associate members, 
in our principal cities, belonging to the medical profession, whose 
names are the best evidence of their fitness for the duty. 

The following paper on “ Amputations through the foot and at 
the ankle joint,’’ belongs to this series, and is respectfully recom¬ 
mended by the Commission to the medical officers of our army now 
in the field. 

Fred. Law Olmsted, 

Secretary. 


Washington, Dec. 6 th , 1861. 



BONES OF THE FOOT AND ANKLE-JOINT. 


Surgical Anatomy. 

a and b. Inferior Extremity of the Tibia and Fib-la; a, Astragalus; d, Os Calcis; e, Scaphoid; 
' ® Ub0ld; In,erDaI Cuneiform; h, Middle Cuneiform; i, External Cuneiform; 1 2 8 4 and 
’ ‘ rSt ’ Seoond > Tli,r<i » Fourth, and Fifth Metatarsal Bones; k, k, k, k, k. Phalanges of the Toes 














REPOET. 


It is proposed in this paper to consider briefly those opera¬ 
tions in the region of the foot which are generally regarded as 
conservative. They are all undertaken with a view either to 
preserve the largest extent of the extremity possible for subse¬ 
quent unaided service, or to adapt a stump that affords the 
best medium for mechanical appliances. 

PRESERVATION OF INDIVIDUAL TOES. 

It is always desirable to preserve as many of the phalanges 
as possible. If the injury is of such a nature as to require the 
sacrifice of all but one toe, this should be preserved. The sup¬ 
port which is given to the foot in the mechanism of progression, 
by even the small toe alone, is sufficient to warrant its preser¬ 
vation. Especially is it important to save the great toe, which 
forms so considerable a part of the foot. 


AMPUTATION OF TUE METATARSO-PIIALANGEAL ARTICULATION. 

When the injury requires the sacrifice of all the toes, the 
surgeon should, if the soft parts permit, remove them at their 
articulation with the metacarpal bones. The resulting extre¬ 
mity will be extremely serviceable without artificial aid. 

Operation. —1st. The operator, grasping all the toes in his 
left hand, makes, with a narrow knife, a semi-circular incision, 
extending (for the left foot, and vice versa) from the internal 
border of the first metatarsal bone, to the external border of the 



6 


fifth, in front of the articulation of the toes with the metatarsus. 
2d. The articulations are opened in succession with the point 
of the knife, and their ligaments divided. 3d. The knife is 
then carried behind the phalanges for the purpose of cutting 
out a semi-circular flap from the plantar surface of the foot.— 
Lisfrands Method in Bernard and Iluette. 

EXCISION OF INDIVIDUAL METACARPAL BONES. 

It occasionally happens that the local injury is of such a 
nature that by careful dissection the individual metacarpal 
bones may be removed, and the remainder of the foot be pre¬ 
served. This is always preferable to any more considerable 
mutilation of the foot, and should not on any account be over¬ 
looked. 

AMPUTATION AT THE TARSO-METATARSAL ARTICULATION. 

If the injury involves so much of the extremity of the foot 
as to raise the question of amputation at a point higher than 
those already indicated, the surgeon should make every exer¬ 
tion to save the tarsus entire. If the soft parts allow it, this 
can be accomplished by amputation at the tarso-metatarsal 
articulation. The following description of the operation is 
condensed from Bernard and Iluette:— 

To recognise the Articulation. —1st. On the inner side of the 
foot carry the finger backward along the inner border of the 
metatarsal bone until a projection is encountered, one or two 
lines beyond; this is the articulation, situated in a depression 
between the two projections. The articulation may also be 
found just one inch anterior to the prominence of the scaphoid 
bone. 2d. On the outer side follow the external border of the 
fifth metatarsal bone, until the prominence at its proximal 
extremity is recognised; the articulation lies immediately 
behind it; in some instances, the head of the metatarsal bone 
projects a trifle beyond the articulation. 



7 


Modes of Operating. —1st. The patient is placed upon his 
back, and the foot rotated moderately inwards. The surgeon 
recognises the exact situation of the articulation by the rules 
already laid down, and then grasps, with the palm of his left 
hand, the sole of the foot, his thumb being placed on the outer 
side of the proximal end of the fifth metatarsal bone, and the 
index finger at the internal extremity of the articulation. He 
then makes a semi-lunar incision with its convexity looking 
downwards, from without inwards, across the dorsum of the 
foot, passing about half an inch below the articulation, and 
extending from one of its extremities to the other down to 
the bones. 

2d. The surgeon divides, with the point of his knife, the 
dorsal ligaments, carrying it along the line of the articulation 
from without inwards, as already indicated, and recollecting 
that the articulation of the second metatarsal lies a third of an 
inch posterior to the others. 

3d. The mortise in which the head of the second metatarsal 
is inclosed remains to be opened. This is effected by intro¬ 
ducing the point of the knife between the internal cuneiform 
and the head of the first metatarsal bone, its edge being turned 
upwards, and making an angle of 45° with the axis of the foot. 
The knife is then carried up to a right angle, its point travers¬ 
ing the whole of the inner surface of the mortise, in order to 
insure the division of the interosseous ligament; it is then with¬ 
drawn, and applied to the external surface of the mortise. 

4th. When this has been accomplished, pressure is made 
upon the metatarsus to separate the articular surfaces, and their 
remaining ligamentous attachments are successively divided, 
especially those on the plantar aspect of the articulation, so 
that the knife may be carried readily beneath the heads of the 
metatarsal bones, and the operation is then finished by cutting 
out a flap from the sole of the foot, which should be somewhat 
larger at its internal than at its external part.* 

* The operation above described is generally known in this country as Lisfranc's 


8 


AMPUTATION AT THE MEDIO-TARSAL ARTICULATION. (CHOPArt’s 

OPERATION.) 

To recognise the Articulation. (Condensed f rom Bernard 
and Huette .)—The articulation at the middle of the tarsus is 
formed by the astragalus and the os calcis behind, and by the 
cuboid and scaphoid in front; the inter-articular line which 
crosses the foot transversely resembles the italic of which 
the anterior convexity is internal and its posterior convexity 
external. The internal extremity of the articulation is just 
one inch in front of the internal malleolus, and two lines and a 
half behind the tuberosity of the scaphoid. The external ex¬ 
tremity is half an inch behind the projection formed by the 
head of the fifth metatarsal bone. It corresponds with a 
prominence on the external surface of the cuboid bone, which 
is situated just one inch in front of the external malleolus. 
The centre of the articulation lies immediately in front of the 
head of the astragalus, which can be made to project by 
forcibly extending the foot. On the outside of this prominence 
is a depression sensible to the touch, lying between the astra¬ 
galus, the cuboid, and the os calcis; the articulation is imme¬ 
diately in front of this. 

Rules in Operating. —1st. The exact position of the articula¬ 
tion having been recognised by the means above indicated, the 
surgeon grasps the foot with his left hand, its sole being placed 
in his palm, his thumb upon the external extremity of the 
articulation, and the index finger upon the tuberosity of the 
scaphoid bone ; 2d. The knife is then to be carried across the 
dorsum of the foot from the thumb towards the index finger, 
making a semi-circular incision which descends about half an 
inch below the line of the articulation; 3d. After the retrac¬ 
tion of the integuments, divide the tendons which remain uncut 
and open the articulation, bearing in mind the varying obliquity 

operation on the foot, and it is distinguished by this title from Heps operation 
through the metatarsus. 


9 


of the articular surfaces as already indicated, and also to divide 
thoroughly the fibrous bands connecting the scaphoid and 
astragalus before attempting to enter the joint, as the thin edge 
of the scaphoid juts over the latter in some degree ; 4th. The 
articulation being entirely laid open, and all its ligaments freely 
divided, pass the flat of the blade behind the bones, and having 
brought up the end of the foot into its natural position, cut out 
a flap from its plantar surface, which should extend beyond the 
sesamoid bones in order to possess sufficient length; the knife 
should graze the bones in making the flap, care being taken to 
avoid the projections of the scaphoid, cuboid, and first and fifth 
metatarsals. 


AMPUTATION AT THE ANKLE JOINT. 

Amputation at the ankle joint was performed with very in¬ 
different success by the older surgeons. The failure was due 
rather to the inutility of the stump, than to the mortality after 
the operation. It was their invariable practice to make the 
flaps from the tissues about the ankle, and, with but rare ex¬ 
ceptions, they left the malleoli undisturbed. The first difficulty 
which they experienced was in closing the wound over the 
projecting malleoli, and the second was the protrusion of these 
processes through the meagre covering of the stump, when the 
patient began to use his limb. Unfavorable as were the cir¬ 
cumstances attending the early methods of performing this 
operation, still, many cases are on record in which a useful 
limb was obtained, due, doubtless, to the entire or partial 
absorption of the malleoli. Amputation at the ankle joint did 
not, therefore, obtain a place among the legitimate operations 
of the earlier surgeons. It may fairly be questioned if opera¬ 
tive surgery has in any instance made a more important 
advance toward the realization of its humane purposes of 
saving life and restoring useless limbs than in this single par¬ 
ticular of amputation at the ankle joint. Previously to 1843, 
in all affections of the foot involving its removal, amputation 


10 


was performed through the leg. The mortality after this ope¬ 
ration, always considerable, varies with circumstances. In the 
Parisian hospitals it has been estimated as high as fifty per 
cent., even when performed for chronic disease, a condition 
most favorable to success. American hospitals give thirty- 
seven per cent., and English hospitals nearly twenty per cent.; 
a fair average of the mortality of this operation, may be put at 
twenty-five per cent. In 1S50, Mr. Syme stated {Monthly 
Jour.) that he had performed amputation at the ankle between 
thirty and forty times, with the loss of but a single patient, 
and in this case the unfortunate result was not due to the opera¬ 
tion. More recently he remarks, “ the operation itself I believe 
to be as free from risk as the removal of a finger or toe.” 

There are now two principal methods of amputation at the 
ankle joint known respectively by their projectors as Syme’s 
and Pirogoff’s operations. The relative merits of these opera¬ 
tions will be more easily appreciated by describing the methods 
pursued and grouping the facts which experience has thus far 
accumulated. 


Syme’s Method. 

Operation .—The foot being placed at a right angle to the 
leg, a line drawn from the centre of one malleolus to that of the 
other, directly across the sole of the foot, will show the proper 
extent of the posterior flap. The knife should be entered close 
up to the fibular malleolus, and carried to a point on the same 
level of the opposite side, which will be a little below the tibial 
malleolus. The anterior incision should join the two points just 
mentioned at an angle of 45°, to the sole of the foot and along 
the axis of the leg. In dissecting the posterior flap, the ope¬ 
rator should place the fingers of his left hand upon the heel, 
while the thumb rests upon the edge of the integuments, and 
then cut between the nail of the thumb and tuberosity of the 
os calcis, so as to avoid lacerating the soft parts, which he,-at 
the same time, gently but steadily presses back until he exposes 
and divides the tendo Achillis. The foot should be disarticu- 


11 


lated before the malleolar projections are removed, which it is 
always proper to do, and which may be most easily effected 
by passing a knife around the exposed extremities of the bones, 
and then sawing off a thin slice of the tibia connecting the two 
processes.* Mr. Syme directs the articular surface of the tibia 
always to be removed. This, certainly, should be done, if the 
disease has attacked the part; but, if healthy, it seems to be 
unnecessary. In one of the writer’s cases, the extremity 
of the tibia was removed, but without any apparent benefit as 
respects the result. The following wood-cuts, of reduced size, 

taken from similar illustra¬ 
tions in the Monthly Jour¬ 
nal, Feb. 1850, give a more 
correct idea of the line of 
incision than can any verbal 
description. It will be seen 
that they differ very mate¬ 
rially from those given in 
text books. The principal 
precaution to be observed, is in the dissection on the posterior 
part of the os calcis, in order not to wound the posterior tibial 
artery, and thus deprive 
the flap of its nourishment. 

It is recommended by some 
surgeons to disarticulate be- 
fore dissecting the posterior 
flap. This proceeding in¬ 
creases the liability to 
wound this vessel, nor 
does it facilitate the ope¬ 
ration. The artery may readily be avoided by keeping the 
edge of the knife constantly turned from the flap toward the 
bone. By this means also, the operator will not be liable to 
puncture the posterior flap—an accident which has occasion¬ 
ally occurred, but which does no harm. 

* Syme’s Contributions to Surgery. 






12 


Pikogoff’s Method. 

4 

Operation — The following description of this method is 
taken from a London Medical Journal, and was translated 
from the author:— U I commence my incision close in front of 
the outer malleolus, carry it vertically downwards to the sole of 
the foot, then transversely across the sole, and lastly obliquely 
upwards to the inner malleolus, where I terminate it a couple 
of lines anterior to the malleolus. Thus all the soft parts are 
divided at once quite down to the os calcis. I now connect the 
outer and inner extremity of this first incision by a second 
semilunar incision, the convexity of which looks forward, car¬ 
ried a few lines anterior to the tibio-tarsal articulation. I cut 
through all the soft parts at once down to the bones, and then 
proceed to open the joint from the front, cutting through the 
lateral ligaments, and thus exarticulate the head of the astra¬ 
galus. I now place a small narrow amputation saw obliquely 
upon the os calcis behind the astragalus, exactly upon the sus¬ 
tentaculum tali, and saw through the os calcis, so that the saw 7 
passes into the first incision through the soft parts. Saw 7 care¬ 
fully, or the anterior surface of the tendo Achillis, which is 
only covered by a layer of fat and a thin fibrous sheath, might 
be injured. I separate the short anterior flap from the two 
malleoli, and saw through them at the same time close to their 
base. I turn this flap forwards, and bring the cut surface of 
the os calcis in apposition w T ith the articular surface of the tibia. 
If the latter be diseased it is sometimes necessary also to saw 
off from it a thin slice with the malleoli.” 

Pirogoff believes also that the tendons should not be cut off 
too short, in other words “ not too near the spot where their 
synovial sheaths are cut through ; their ends should rather pro¬ 
ject a little. If they are cut too short they conceal themselves 
in the fibrous canal, or what is worse, when the limb is moved 
they slip upwards out of their sheaths.” He adds :—“ I fear 
nothing so much as this, namely, when the belly of the muscle 



13 


contracts, and draws up the tendon divided, or half destroyed 
by suppuration, out of the sheath. I am convinced that the 
fixing of the tendons before and during the operation by 
methodical pressure, and the continuous maintenance of the 
limb in one and the same position by the plaster of Paris ban¬ 
dage, may contribute a great deal towards the successful result 
of these operations.” 

The following description of the several steps of the opera¬ 
tion as more recently performed, is given by Mr. Croft 
(London lancet , Feb. 6, 1858), one of the surgeons of the 
Dreadnought Hospital, where the operation had, at that date, 
been performed six times. He says :— 

u The mode of operation, as performed by Mr. Busk, Mr. Tudor, and 
myself, is to grasp the projecting portion of the foot with the left hand, 
then to enter the point of the knife immediately behind the malleolus, 
and make a semi-circular incision in front of the point, terminating at a 
corresponding point behind the opposite malleolus; next, to carry the 
incision downward and slightly forwards to the edge of the sole of the 
foot, straight across the sole, and terminate it at the opposite malleolus, 
or the point at which the incision was commenced. Having disarticu¬ 
lated the foot, the soft parts are to be separated from around the os cal- 
cis in a line from the posterior margin of the upper articulating surface 
to the under edge of the articulating surface of the cuboid, and the 
mass in front of this line to be removed by the saw. The ends of the 
tibia and fibula are sawn off in the way usual in Syine’s operation. 
During the process of separating the soft, or rather tough parts about 
the os calcis, care should be taken to keep the edge of the knife close 
to the bone, in order to avoid wounding the posterior tibial or plantar 
arteries. The portion of the os calcis left on the flap should be placed 
in contact with the end of the tibia, and if the saw has been entered 
well behind the calcaneo-astragaloid articulation, and brought out at 
the under margin of the calcaneo-cuboid articulation, the contact will 
be accurate. If the bones cannot be placed in accurate contact, thin 
slices of bone from the upper and back part of the portion of the os 
calcis should be removed by the saw until they can be adapted. The saw 
we prefer is Bigg and Milliken’s modification of Butcher’s Dublin saw.” 


14 


REMARKS. 

In deciding upon the point of amputation, surgeons are 
very properly governed by the following simple rules:— 

1st. The comparative danger of the operation ; and 

2nd, The comparative usefulness of the stump. 

If there were two given points at which an amputation 
might he performed, no prudent surgeon would select the one 
having the largest mortality, unless the ultimate advantages 
were of the utmost importance to the usefulness or happiness 
of the patient. Of the operations on the foot which we have 
passed in review, it may be said that in all which involve the 
parts anterior to the medio-tarsal, or Chopart’s amputation, 
these two conditions combine to determine the surgeon to save 
as much of the extremity as possible. The mortality of the 
operation diminishes and the usefulness of the limb increases 
in proportion to the amount preserved. There can be no 
doubt, therefore, that it is the duty of the operator to preserve 
as much of the anterior portion of the foot as possible. 

But new and important questions arise when we attempt to 
decide upon the value of the three remaining operations by 
the rules proposed. With a view to a proper appreciation of 
the alleged advantages and disadvantages of these amputa¬ 
tions, in order to arrive at correct conclusions as to their com¬ 
parative merits, we present the following summary of opinions 
by surgical authorities. 

Chopart's Operation .— Chopart’s operation has now been 
practised nearly three-quarters of a century, and has been, 
during the whole period, the subject of severe criticism. On 
the one hand it is contended that the stump is entirely ser¬ 
viceable, that the operation is attended with slight mortality, 
and that by it an important portion of the foot is preserved. 
On the other, it is asserted that the stump is generally tender, 
very often affected with incurable ulcers, and, finally, that the 
extremity of the stump is liable to become the most depending 


15 


portion, and the cicatrix the point of support. Some attribute 
this tendency to retraction of the heel to the action of the feebly 
antagonized extensors of the foot, and others to the removal 
of one half of the arch of the foot. Whatever may be the 
explanation, it is certain that surgeons have constantly met 
with this position of the stump, and endeavor to remedy it. 
Within three years of its first introduction, Petit divided the 
tendo Achillis to relieve the defect, and this operation has 
often been repeated since. 

Reports unfavorable to the operation have frequently been 
made by Surgical Authorities. In 1815 Villerme reported 
a score of cases in which the patients could walk well only 
from live months to two years after the operation. Bouvier 
recently read a paper before the Society of Surgery, Paris, in 
which he condemned Chopart’s operation in strong terms. 
According to him, bad results almost invariably follow in time; 
these patients fill the hospitals of incurables; section of the 
tendon is only a temporary expedient, and the difficulty returns 
on its reunion ; he therefore advised its rejection. 

In reply to this communication, Chassaignac declared the 
amputation of Chopart to be an excellent operation, and referred 
to cases in which the patients walked well without division of 
the tendon, to others where the division of the tendon relieved 
the difficulty, and finally to some who walked freely upon the 
face of the stump itself. He thought the operation should not 
be rejected, but be perfected, since it was very safe ; the 
division of the tendo Achillis is now very frequently practised, 
either immediately after the operation, or when the heel has 
been elevated and the cicatrix has become the most depending 
portion. 

The opinions of the following well known authorities may be 
added :—Blandin asserts that he has met with retraction of the 
stump but once in eleven amputations. Velpeau did not meet 
with retraction in five cases, and regards it as an exceptional 
occurrence. Hdlaton approves the operation, and thinks retrac- 


16 


tion may or may not take place ; if it occur, division of the 
tenclo Acliillis relieves it for a time at least. Mr. Fergusson 
and Mr. Cock, of London, have remedied this condition by 
division of the tendo Acliillis, and do not consider it a valid 
objection. Mr. S 3 -me, on the contrary, seems to reject CI 10 - 
part’s operation altogether. In some clinical remarks on a case 
upon which he was about to perform his operation, in 1852, he 
said, “ There is extensive disease of the tarsus, not leaving 
room for the performance of Chopart’s operation, even if I 
deemed it expedient, which I have long ceased to do, from 
conviction of its inferiority to that at the ankle, especially in 
regard to the protection afforded against relapse. In one }mar 
alone, I performed three secondary amputations at the ankle 
to remedy the sequelae of Chopart’s operation.” Prof. Gross 
expresses himself strongly in favor of the operation. He 
sa} r s:—“ Of the utility of this procedure, in the class of cases 
under consideration, there can no longer be any doubt; I have 
employed it several times in my own practice, and I have seen 
it repeatedly executed by others, and in every instance that 
has come within my notice, the result has been most satis¬ 
factory.” 

Syme’s Operation. —Sjnne’s method is now an accepted opera¬ 
tion with the surgeons of Great Britain. Mr. Fergusson, who 
had operated eight times, says :—-“In so far as I can judge, it 
is one of the greatest improvements in modern surgery as 
regards the subject of amputation.” Mr. Ericlisen remarks 
that it “ constitutes one of the greatest improvements of recent 
date in operative surgery, as by its performance amputation of 
the leg may often be avoided, and the patient being left with 
an exceedingly useful stump, the covering of which being 
ingeniously taken from the heel, constitutes an excellent basis 
of support.” Mr. Quain thinks the operation “ free from any 
valid objection, and, what is more important, the result in 
practice has been found to be good. A person who has under¬ 
gone this operation is enabled to bear his whole weight upon 


17 


the end of the stump without inconvenience ; and, on this 
account, the facility of progression is, with a proper apparatus, 
decidedly greater than when the amputation is performed at 
any higher part of the limb.” 

On the contrary, it is alleged against this operation— 

1st. That it is difficult and tedious . But Mr. Syme states 

that he requires less time than a minute to perform it. 

2d. That the flap is liable to slough. This, however, rarely 
takes place to any considerable extent. Mr. Syme says:— 
“ That the flap may, and probably will still occasionally slough, 
is unhappily too true, hut that this result is always owing to an 
error in the mode of performance, I think does not admit of 
any question. For as the integument being detached from its 
subjacent connexions, can derive nourishment only from the 
anastomosing vessels, it is evident that if scored crossways, 
instead of being separated by cutting parallel to the surface, 
the flap must lose its vitality.” 

3d. That there is a necessary delay in the healing of the 
wound. From recent statistics it appears that union is much 
more prompt, in a given number of cases in Syme’s than in 
Chopart’s amputation. Dr. Van Buren, of New York, has met 
with union by the first intention ; in a case which recently 
came under the writer’s observation, the patient bore her 
weight on the stump on the fifteenth day, union being at that 
date complete. 

4th. That the stump is sensitive , and hence not serviceable. 
Mr. Syme remarks :—“ Patients who had suffered the operation, 
were able to stand, walk, and even run, without any covering 
or protection of the stump ; and a gentleman present, having 
had his attention accidentally directed, a few days before, to 
some boys who were amusing themselves on a slide in the 
street, discovered that one of them had undergone amputation 
at the ankle joint.” D e. Van Bueen, of New York, states 
that a patient recently presented himself at the College clinic 
of the University Medical College, on whom Mr. Syme 

2 


18 


performed his operation sixteen years ago, being the third 
person on whom the operation was performed, who stated that 
he had walked thirty miles in a day without inconvenience 
from his stump. We may add the following fact, which came 
under our own observation :—A man presented himself at 
Bellevue Hospital during the last winter, who had undergone 
amputation at the ankle joint, by Dr. Carnociian, a year or 
more previously. lie was a book-peddler by occupation, and 
stated that he not unfrequently walked eight miles daily, with¬ 
out fatigue or inconvenience from his mutilated limb. He had 
but a very slight limp. He wore a short shoe, with the sole 
raised sufficiently to compensate for the loss of the foot. We 
may add that recent statistics show that but a single case is 
authenticated of a stump so sensitive as not to admit the weight 
of the body. 

Pirogoff’s Operation .—Pirogoff claims for his method of 
amputation the following advantages :—1. The tendo Achillis 
is not divided, and we avoid all the disadvantages connected 
with its injury. 2. It also follows that the base of the posterior 
flap is not thinner than its apex, while the skin on the base of 
the flap remains ununited with the fibrous sheath of the tendo 
Achillis. 3. The posterior flap is not cap-like, as in Syrne’s 
method, and its form is therefore less favorable to a collection 
of pus. 4. The leg after this operation appears an inch and a 
half (sometimes even more) longer than in the three other ope¬ 
rations (Syme, Baudens, Roux), because the remnant of the os 
calcis left in the flap, as it unites with the inferior extremities 
of the tibia and fibula, lengthens them by an inch and a half, 
and, 5. Serves the patient as the point of support. 

Mr. Croft furnishes the following account of the six cases 
occurring at the Dreadnought:—“ Six times the operation has 
been performed, and in four instances with most perfect success ; 
but in the two remaining death removed the subjects of ope¬ 
ration before cure was completed—iirthe first instance by gra¬ 
nular disease of the kidneys, and in the second instance by 


19 


secondary deposits of pus in various joints. In two of the six 
cases in which cure was completed, the operation was per¬ 
formed for the removal of scrofulous disease of the articulation 
between the tarsal bones; and in the two others the operation 
was for frost-bite of the anterior part of the foot. Progress 
towards health was marked by suppuration along the tendons 
of the tibialis anticus and posticus, and the peroneal tendons in 
each of the cases, but not by exfoliation of bone. The posterior 
part of the os calcis w r as united firmly with the tibia, generally 
in about three weeks ; but in one instance—the last in which 
the operation was performed—union was good at the end of 
twelve days. I may here remark, that although the os calcis 
may be diseased at and about its articulation in instances of 
scrofulous disease of the joints of the tarsus, it is rarely that the 
posterior part is rendered too unhealthy to be made use of in 
the formation of a stump. The advantages of this operation 
over “ Syme’s” (the only operation with which it can be com¬ 
pared) are, that it may be performed more rapidly as to time, 
leaves a more vascular flap, forms a longer stump, and produces 
a firmer pad for the subject to walk upon. Less time is occu¬ 
pied in the operation, for the somewhat troublesome dissection 
of the skin of the heel from the os calcis is avoided, and the os 
calcis sawn through instead. Greater vascularity of the flap is 
secured, for the plantar arteries are divided in the hollow of the 
foot. The length of the stump is a very important point; it is 
longer than in Syme’s operation, by the portion of the os calcis 
left on the flap, which should be quite one inch and a quarter. 
In the four instances mentioned, the difference in length between 
the foot operated upon and the sound foot, was never more than 
three eighths of an inch.” 

Mr. Busk, of the same hospital, who lias operated three times, 
says, “ Greater facility and rapidity of execution; less disturb¬ 
ance of the natural relations of the parts which are to form the 
cushion of support ; a solid instead of a hollow flap 5 and, lastly, 
a greater length of stump, amounting to at least one inch and 


20 


a half—are such recommendations as few will he found to deny, 
and against which nothing, so far as I can perceive, is to he 
opposed.” 

In regard to the liability to non-union of the fragment of os 
calcis, we have the following testimony. Pirogoff says of his first 
three cases, “ notwithstanding the suppuration and considerable 
gravitation of pus into the flap in the third case ; notwithstand¬ 
ing the softness and fatty degeneration of the os calcis, which 
could he cut with the knife, in the second case ; and lastly, not¬ 
withstanding the bleeding fungous excrescences which formed 
on the hones, also in the second case ; still the remains of the os 
calcis united firmly with the tibia and fibula. Lastly, one of 
the cases, the third, proves that the exarticulation at the ankle 
joint after my method—at least in children and young people— 
may be undertaken even in cases of diseased ankle joint, pro¬ 
vided disorganization has not extended too far over the soft 
parts about the articulation. In the boy in the second case, I 
found pus in the capsule during the operation, the cartilages 
softened and decayed, the ends of the bones also softened, and 
in a state of fatty degeneration, yet the result of the operation 
was most successful.” 

Mr. Busk says :—“ Some have feared that the section left of 
the calcaneum would not readily unite with the extremity of 
the tibia; but this fear is groundless. In the last operation 
performed by Mr. Tudor union was found to be quite firm on 
the twelfth day. ... In my first case the man could support 
his whole weight on the stump within a fortnight.” 

A correspondent of a London Medical Journal thus records 
an interview with Mr. Syme : “ Mr. Syme spoke of it (Piro- 
goffs operation) with much contempt, alleging that the retained 
extremity of the os calcis would, in the first place, be likely to 
act as a foreign body, and cause irritation, and that even if good 
union were obtained the limb would be too long to be useful. 

. . . I can only say that some of the best stumps that I have 
ever seen have been obtained by it, and that so far from the 


21 


portion of os calcis acting as a foreign body, it usually unites 
easily and firmly to the tibia. In London the operation has 
been performed by Mr. Ure of St. Mary’s, by Mr. Simon of St. 
Thomas, by Messrs. Busk, Tudor, and Croft at the Dread¬ 
nought, and by Mr. Fergusson and Mr. Partridge in King’s 
College ; all of whom have, I believe, been, on the whole, well 
satisfied with its results. At the Glasgow Royal Infirmary, 
Dr. McGhee, the Medical Superintendent, showed me a case in 
which it had been performed seven weeks previously. The 
stump was just healed, and promised to be an excellent one. 
It was, I understood, the first case in Glasgow in which that 
operation had been adopted.” 

The objections generally raised to this operation, are thus 
summed up by Mr. Syme, in comparing it with his own method. 
He alleges that “ this operation deprives his of all its advan¬ 
tages in the first place, by rendering it complicated instead of 
extremely simple ; secondly, by making the stump too long; 
thirdly, by impairing its constitution; fourthly, by retaining a 
portion of the osseous tissue justly liable to the suspicion of 
relapse ; and fifthly, by not being applicable to all cases requir¬ 
ing amputation at the ankle.” The preceding opinions quoted 
from surgeons who have had experience in this operation, prac¬ 
tically refute these objections. They all regard Pirogoff’s ope¬ 
ration as the more simple ; the greater length of the limb is 
considered an advantage to the poor man who has no artificial 
limb ; the stump is thought to be more sound and serviceable; 
the liability of the osseous portion of the flap to necrosis is 
denied ; it is deemed applicable to all cases suitable for Syme’s 
operation, provided only the posterior portion of the os calcis is 
not diseased. 

PirogofFs operation has now been performed upwards of twelve 
times by the surgeons of Great Britain; and all who have ope¬ 
rated, have spoken favorably of it. 


22 


GENERAL APPRECIATION OF THE AMPUTATIONS OF CIIOPART, SYME, 

AND PIROGOFF. 

Taking the foregoing facts as the basis of an appreciation of 
the comparative merits of these several operations, with such 
suggestions from experience as may occur to us, we are pre¬ 
pared to determine their relative value, and definitively apply 
the rules in operative surgery already stated. 

1st. The Operation decided by Comparative Mortality. —Sta¬ 
tistics do not determine with sufficient accuracy the compara¬ 
tive mortality of these several amputations. It does not appear 
that the influence of the diseases or accidents for which ampu¬ 
tation was undertaken, upon the mortality, is estimated in these 
summaries. Chopart’s operation has always been regarded 
as attended with veiy little danger. In Mr. Syme’s ex¬ 
tensive experience in his own operation, the mortality is al¬ 
most nominal. He states that he regards it as no more 
fatal than amputation of the finger; in 40 cases, he had 
but one death, and that was not fairly attributable to the 
operation. From our own observations we should not re¬ 
gard Syme’s operation as any more fatal than Chopart’s, in 
the same individual cases. Nor can we believe, if we attach 
proper importance to the opinions of the eminent surgeons who 
have practised Pirogoff s method, already brought forward, that 
independently of the co-existent disease or injury, this operation 
is more dangerous than either of the two preceding amputations. 
All speak with great confidence of its safety. If to the fore* 
going facts we add the additional consideration, that the danger 
in all these operations is for the most part the same, viz. the 
liability to suppurative inflammation in the sheaths of the 
divided tendons, we can but believe that the actual mortality 
from the three operations is not widely different. We may 
conclude, therefore, that— 

The comparative mortality of Chop art's, Syme’s , and Piro¬ 
goff's amputations is too slight to influence the Surgeon in his 
selection but— 


23 


2d. The individual operation shoidd be determined by the 
Serviceableness of the Stump. —This question involves, accord¬ 
ing to previous rules in determining the point of election in 
amputations, the social condition of the patient. The poor 
man’s and the rich man’s leg have long decided the point of 
amputation of the lower extremity. This distinction is made 
in the belief that the poor man will either have no artificial 
appliance to his stump, or one of the rudest character, while 
the rich man will avail himself of the highest degree of art to 
compensate his loss. This question must always present itself 
to the military surgeon, if the rule remains valid, for in the 
ranks of every army w r e find, as in society at large, persons 
filling every grade of social position. 

In our time, when mechanical surgery is doing so much to 
supply the maimed with serviceable limbs, and in this country, 
where public and private charity is so lavish in the relief of 
suffering, and the poorest may, by economy, accumulate wealth, 
the question may well be mooted if this old rule in operative 
surgery should longer govern the surgeon. Especially may 
we doubt its propriety, when the subject of the operation is 
under middle life. The instances are becoming more and more 
frequent where persons in humble circumstances, who have had 
a limb removed according to this rule, have subsequently been 
able to supply themselves with artificial aids, and have bitterly 
regretted that they have been deprived of the opportunity by 
the surgeon. It cannot be denied that in such cases the rule 
has operated to the serious disadvantage of the patient. We 
must conclude, therefore, that with American surgeons this 
rule should be modified thus : 

Under all circumstances , except ichere poverty and advanced 
aye , and confirmed dissolute habits , so combine in the indivi¬ 
dual, as to render it certain that mechanical appliances would be 
of little service , give the patient the stump best adapted to the 
most usefid artificial limb. 

The two following questions grow out of this conclusion : 


24 


1st. Of the three above-mentioned operations, which gives 
the most useful stump for progression without aid ? 

2d. Which affords the best stump for artificial appliances ? 

In regard to Chopart’s amputation, it has been seen that the 
testimony of surgeons is very conflicting as to the usefulness of 
the stump. It cannot, we think, be denied, that it has frequently 
required subsequent interference, such as division of the tendo 
Achillis, a support under the anterior part of the stump, &c., 
in order to prevent such a degree of retraction of the lieel as 
would bring the cicatrix to the most dependent part. Indeed, 
no one can examine the normal relations of the tarsal bones 
without being struck with the fact, that by this operation more 
than half of the anterior part of an arch is removed, leaving the 
remaining portion to sustain the entire weight which before 
belonged to the whole. It could scarcely result otherwise than 
that, in a well-formed foot, the posterior half of the arch would 
fall under the superincumbent weight. If we add to this, the 
constant elevation of the heel by the powerful and feebly anta¬ 
gonized muscle of the calf, we can only be surprised that in 
time every stump of this kind is not turned with its face down¬ 
wards. And it must be admitted by the most ardent advocates 
of this operation that in some instances it has been found im¬ 
possible to remedy these defects, and patients have remained 
permanently unable to bear their weight upon the stump. 

It has been alleged, as already noted, that in Syme’s operation 
the stump is often so tender that the patient cannot bear his 
weight upon it. Such an opinion would seem to be rather 
theoretical than practical. We do not know of any well- 
founded proofs that such a result follows. On the contrary, 
Mr. Syme’s testimony, as we have already stated, coincides 
with our own experience, that the stumps are capable of great 
endurance. Of Pirogoff’s operation we cannot speak as confi¬ 
dently, from want of sufficient evidence ; but it will be seen in 
the preceding pages, that so far as we have obtained the opinions 
of those who have had the most experience, the stumps, when 






25 


firmly healed, are capable of sustaining any desirable degree 
of direct use. It must not be overlooked, however, that 
sinuses occasionally form, leading to carious bone, which long 
remain a serious drawback to the usefulness of the stump. 

We are authorized in concluding:— 

That the stump after Byrne's or Pirogojf’s operation is the 
most serviceable , without artificial aid ; preference being given 
to the former. 

The question of adapting artificial limbs to these several 
stumps mainly rests with those engaged in mechanical sur¬ 
gery. So far as we have been able to ascertain the facts, 
Syme’s operation gives much the best stump for an artificial 
extremity. Although a foot can be supplied cheaply in 
Chopart’s amputation, yet it but poorly remedies the defect, 
and does not improve the patient’s power of walking. An 
artificial limb may be applied to Syme’s stump, which both 
relieves deformity, and renders the patient’s gait free from the 
slightest halt. The following opinion of an intelligent mecha¬ 
nical surgeon, of great experience, is worthy of notice :— 

“ Among the numerous instances of mutilated feet through 
the tarsus, which fall to our care for treatment, it is seldom 
that w r e are able to designate a perfectly satisfactory stump, one 
to be preferred to what might have been made of parts conti¬ 
guous. Hine-tenths of the mutilations, as by Chopart, present 
one or more of the following diagnostics, to wit: First , of an 
insufficient covering ; caries, more or less, of the remaining 
tarsal bones ; ulceration of the surrounding soft parts, or that 
of a thin shining pellicle of covering, exceedingly susceptible, 
quickly inflamed, and abraded by the least exposure, which 
renders it hazardous or difficult to attempt the application of 
any substitute. Second , a total inability to flex the stump, and 
to preserve its normal position at a right angle with the line of 
the leg; a morbid contraction of the gastrocnemii muscles 
(without antagonism), and retraction of the heel; a pendent 
position of the end of the stump, and exposure of the cicatrix 


26 


to be pressed to the ground by the weight of the body, with its 
general inutility for walking. No possible advantage can be 
obtained by an amputation of the foot which involves in the 
sacrifice the greater portion of the tarsus, but what will be 
largely enhanced by a well-timed operation at the anlde-yoiat , 
after the mode of Mr. Syme: therefore, by every consideration 
of humanity and art, I am led to regard that site as the one 
which should be designated as the second place of election.” 

We are not aware that any artificial limb has yet been 
devised for the stump after PirogofFs amputation. We may 
add, that those skilled in the manufacture of artificial limbs 
consider this stump very poorly adapted for a useful mecha¬ 
nical contrivance. 

We conclude:— 

That the stump after Syme's amputation is much "better 
adapted for an artificial appliance than that resulting from 
either Choparfs or Pirogoff's operation. 

After Treatment. —The subsequent treatment of operations 
of the foot is of great importance, as regards their ultimate 
success. Although immediate union is always desirable, yet it 
is not always attainable, even under the most favorable circum¬ 
stances, as where operations are performed in the immediate 
vicinity of lacerated wounds, as must frequently occur in 
attempts to save fragments of the foot. Union by granulation 
cannot be anticipated. In view of the liability of the wounds 
left after amputations through the foot, and the excision of 
bones, to suppuration, and the consequent dangers of pyaemia, 
the practice of leaving them open to heal by granulations is 
becoming more and more general. The process of cure pro¬ 
ceeds more favorably in a given number of cases thus treated, 
than when the wound is at once closed ; and the cicatrix which 
forms under these circumstances is both symmetrical and useful. 

We deem it advisable also, in Syme’s amputation, not to 
close the wound immediately. Owing to the constant oozing of 
blood in four cases performed in Bellevue Hospital the stump* 


27 


was not dressed for several hours. The limb was placed in 
an elevated position, and cold water freely applied. The 
advantages of this delay were evident; the deep cavity formed 
by the extremity of the heel in the posterior flap contracted to 
a small size, which, with the complete cessation of the oozing 
of blood, removed the danger following its collection and dis¬ 
organization in this situation. In every instance when the 
wound was dressed, the posterior flap was found as warm as the 
leg, and quite as sensitive to the prick of the needle, showing 
that its vascular and nervous supply was undiminished. The 
only other fact worthy of notice in the after treatment, was the 
daily injection of tepid water, and disinfecting fluids into the 
cavity of the stump while suppuration continued. By these 
means the internal surface of the wound was cleansed, and the 
process of granulation and adhesion promoted. 

GENERAL CONCLUSIONS. 

I. In all amputations of the Lower Extremity, the Surgeon should be 

GOVERNED IN THE SELECTION OF THE POINT OF OPERATION AND THE METHOD TO BE 
ADOPTED— 

1. By the Mortality of the operations in question ; 

% 

2. By the adaptability of the Stump to the most serviceable artificial 

LIMBS. 

II. In all injuries of the Foot, involving parts anterior to the Medio- 

TARSAL ARTICULATION, THE SURGEON SHOULD SACRIFICE AS LITTLE AS POSSIBLE OF 
THE STRUCTURES ESSENTIAL TO PROGRESSION. He SHOULD PRESERVE 

1. Single Phalanges, the importance of which increases from the small 

TO THE GREAT TOE,' 

2. The Metatarsus, by amputation of the Phalanges, or by the Exci¬ 
sion OF INDIVIDUAL METACARPAL BONES ) 

3. The Tarsus, by amputation at the Tarso-Metatarsal articulation 
(Hey’s or Lisfranc’s method). 

III. Of the amputations through the Tarsus or at the Ankle-Joint, 



28 


PREFERENCE SHOULD BE GIVEN TO SyME’s OPERATION AS AFFORDING A MINIMUM 

Mortality, wiTn a Stump best adapted to an artificial limb. 

IV. In the after treatment of the amputations and resections above 
considered, it is good practice to leave the wounds open to heal by 


GRANULATION. 

STEPHEN SMITH, M.D., 

Chairman. 

- 

VALENTINE MOTT, M.D. 

GURDON BUCK, M.D. 

JOHN WATSON, M.D. 

ALFRED C. POST, M.D. 

WILLARD PARKER, M.D. 

ERNEST KRACKOWIZER, M.D. 

W. H. VAN BUREN, M.D. 


























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SANITARY COMMISSION. 




